Form DSS-5104. Report to Central Registry / CPS Application

Form DSS-5104, "Report to Central Registry / CPS Application," is a critical document issued by the North Carolina Department of Health and Human Services. It serves as a comprehensive tool for reporting incidents or suspicions of child abuse, neglect, or maltreatment to the Central Registry. This form also functions as an application for the Child Protective Services (CPS) program.

Main Uses: The primary uses of Form DSS-5104 include:

• Reporting child abuse, neglect, or maltreatment to the appropriate authorities.
• Initiating an investigation by CPS to ensure the safety and well-being of children.

Components: The form consists of several sections:

1. Reporting Party Information: Details about the person making the report.
2. Subject Information: Information about the child(ren) involved in the incident.
3. Incident Details: Description of the alleged abuse, neglect, or maltreatment.
4. Safety Assessment: Assessment of immediate safety concerns.
5. Services and Actions Taken: Information about any actions already taken.
6. Signatures: Signatures of the reporter and supervisory personnel.

Important Fields:

• Reporting Party Information: Name, contact information, and relationship to the child.
• Subject Information: Name, age, gender, and relationship to the reporter.
• Incident Details: Date, time, location, nature of the incident, and circumstances.
• Safety Assessment: Indication of whether immediate safety concerns exist.
• Services and Actions Taken: Description of any steps taken to address the situation.

Parties Involved:

• Reporting Party: Individuals or professionals with knowledge or suspicions of child abuse.
• Subject(s): Children who may be victims of abuse, neglect, or maltreatment.
• Child Protective Services (CPS): Government agency responsible for safeguarding children's welfare.

Considerations When Filling:

• Accuracy: Ensure all details are accurate and truthful.
• Completeness: Provide thorough information about the incident and parties involved.
• Urgency: Prompt submission is crucial for immediate interventions.
• Confidentiality: Handle sensitive information appropriately.

Required Data:

• Reporter's contact information.
• Child's name, age, and description of the incident.
• Information on safety concerns and actions taken.

Additional Documents: Depending on the severity of the incident, supporting documentation such as medical reports, photographs, or witness statements might be required.

Application Examples and Use Cases:

• Teachers reporting suspected child abuse.
• Medical professionals notifying maltreatment suspicions.
• Family members alerting authorities about potential neglect.
• Community members raising concerns about child safety.

Strengths, Weaknesses, Opportunities, Threats (SWOT):

• Strengths: Facilitates immediate intervention, promotes child safety.
• Weaknesses: Potential inaccuracies due to subjective reporting.
• Opportunities: Streamlined reporting process, improved child protection.
• Threats: Risk of false or malicious reporting.

Related Forms and Alternatives:

• Form DSS-5003: North Carolina CPS Referral Form.
• Alternative Reporting Channels: Hotlines, online portals.

Impact on Future Participants: Proper use of the form can lead to early intervention, protection of children, and improved family well-being.

Submission and Storage: The completed form is submitted to the North Carolina Department of Health and Human Services or local CPS office. It's stored in secure databases for case management and future reference.

Utilizing Form DSS-5104 empowers individuals to report concerns, initiate investigations, and contribute to child welfare, ultimately ensuring the safety and protection of vulnerable children.